Signs and symptoms
Signs and symptoms ( 6 Questions)
A client who is receiving intravenous vancomycin reports feeling dizzy and flushed. The nurse observes that the client has a macular rash on the face and neck. Which of the following actions should the nurse take first?
This is correct because stopping the infusion and notifying the provider are the priority actions for a client who is experiencing signs and symptoms of anaphylaxis, which is a life-threatening allergic reaction to a medication. The nurse should also prepare to administer epinephrine as prescribed.
This is incorrect because administering diphenhydramine as prescribed is not the first action for a client who is experiencing anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some symptoms of an allergic reaction, but it is not effective for reversing bronchoconstriction or hypotension that may occur in anaphylaxis.
This is incorrect because monitoring the client's vital signs and oxygen saturation is not the first action for a client who is experiencing anaphylaxis. Although these are important assessments, they are not as urgent as stopping the infusion and notifying the provider.
This is incorrect because slowing down the infusion rate and observing for improvement are not appropriate actions for a client who is experiencing anaphylaxis. Slowing down or continuing the infusion may worsen the client's condition and delay treatment.
A) This is correct because stopping the infusion and notifying the provider are the priority actions for a client who is experiencing signs and symptoms of anaphylaxis, which is a life-threatening allergic reaction to a medication. The nurse should also prepare to administer epinephrine as prescribed.
B) This is incorrect because administering diphenhydramine as prescribed is not the first action for a client who is experiencing anaphylaxis. Diphenhydramine is an antihistamine that can help relieve some symptoms of an allergic reaction, but it is not effective for reversing bronchoconstriction or hypotension that may occur in anaphylaxis.
C) This is incorrect because monitoring the client's vital signs and oxygen saturation is not the first action for a client who is experiencing anaphylaxis. Although these are important assessments, they are not as urgent as stopping the infusion and notifying the provider.
D) This is incorrect because slowing down the infusion rate and observing for improvement are not appropriate actions for a client who is experiencing anaphylaxis. Slowing down or continuing the infusion may worsen the client's condition and delay treatment.